Int Urogynecol J (2010) 21:1143–1149 DOI 10.1007/s00192-010-1152-y
ORIGINAL ARTICLE
Predictive factors for overactive bladder symptoms after pelvic organ prolapse surgery Tiny A. de Boer & Kirsten B. Kluivers & Mariella I. J. Withagen & Alfredo L. Milani & Mark E. Vierhout
Received: 9 January 2010 / Accepted: 22 March 2010 / Published online: 24 April 2010 # The Author(s) 2010. This article is published with open access at Springerlink.com
Abstract Introduction and hypothesis This study focussed on the factors which predict the presence of symptoms of overactive bladder (OAB) after surgery for pelvic organ prolapse (POP). Methods Consecutive women who underwent POP surgery with or without the use of vaginal mesh materials in the years 2004–2007 were included. Assessments were made preoperatively and at follow-up, including physical examination (POP-Q) and standardised questionnaires (IIQ, UDI and DDI). Results Five hundred and five patients were included with a median follow-up of 12.7 (6–35) months. Bothersome OAB symptoms decreased after POP surgery. De novo bothersome OAB symptoms appeared in 5–6% of the women. Frequency and urgency were more likely to improve as compared with urge incontinence and nocturia. The best predictor for the absence of postoperative symptoms was the absence of preoperative bothersome OAB symptoms. Conclusion The absence of bothersome OAB symptoms preoperatively was the best predictor for the absence of postoperative symptoms. Keywords Overactive bladder . Urgency . Urge incontinence . Frequency . Nocturia . Pelvic organ prolapse T. A. de Boer (*) : K. B. Kluivers : M. I. J. Withagen : M. E. Vierhout Department of Obstetrics and Gynaecology, Radboud University Nijmegen Medical Centre, P. O. Box 9101, 6500 HB Nijmegen, The Netherlands e-mail:
[email protected] A. L. Milani Department of Obstetrics and Gynaecology, Reinier de Graaf Group, Delft, The Netherlands
Introduction Pelvic organ prolapse (POP) is a prevalent problem, which has been reported to affect 50% of parous women [1]. Eleven percent of the women will have undergone an operation for prolapse or urinary incontinence by the age of 80 [2]. Symptoms of an overactive bladder (OAB) are often found in patients with POP. According to the International Continence Society, OAB is defined as urgency with or without urge incontinence, usually with frequency and nocturia [3]. This term can only be used if there is no proven infection or “obvious pathology” [3]. POP is in general not considered as “obvious pathology”. It is generally accepted that OAB is a highly prevalent disorder that increases with age in both sexes and that has a profound impact on quality of life. Community [4, 5] based studies showed that the prevalence of OAB symptoms is higher in patients with POP than without POP. Treatment of POP (surgery, pessaries) results in an improvement of the OAB symptoms [6]. It is not known which factors predict the persistence or disappearance of OAB symptoms after POP surgery. This study focussed on factors which predict the presence of symptoms of overactive bladder after surgery for pelvic organ prolapse.
Methods The study group consist of consecutive women who underwent pelvic organ prolapse surgery with or without mesh in the years 2004–2007 in two large hospitals in the Netherlands (Radboud University Nijmegen Medical Centre and Reinier de Graaf Group Delft). The mesh we used was the Prolift® system. This was used in various combinations in the anterior
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compartment (53%), posterior compartment (65%) and central compartment (18%). All patients included completed questionnaires before surgery and at follow-up. The patient self-reported questionnaire is a composite of internationally well-known questionnaires that have been validated for the Dutch language. It contains disease-specific questions from the validated Dutch translation of the IIQ [7] and UDI [7] and the DDI [8]. Patients rate the amount of bother of each symptom on a five-point Likert scale, from 0 (no complaints) to 4 (very serious complaints). Scores on various domains are composed [9] on the basis of their Likert scale values on a scale ranging from 0 (best quality of life) and 100 (worst quality of life). Preoperatively, all women underwent a full gynaecological examination including the POP-Q quantification score [10] and were invited for a postoperative visit 6 months and 1 and 2 years after operation in which the POP-Q was repeated and questionnaires were filled out. The last available follow-up in each patient was used in this study, and thus, the minimum follow-up was 6 months. Patient characteristics and peri-operative complications were collected from the medical files. Procedures were performed or supervised by senior (uro) gynaecologists. Preoperatively, none of the women were on bladder training or used antimuscarinics. Postoperatively, it appeared that a small number of women had utilised bladder training, usually advised by a general practitioner or physiotherapist in the period between operation and her control visit. None of the patients were on antimuscarinics at the time of follow-up. All data were collected and analysed in the context of a Quality of Care project, which was formally deemed exempt from CME/IRB approval. Measurements For this study, the bother of OAB symptoms was dichotomized in patients who were asymptomatic or with only little or no bother versus those with symptoms and moderate to severe bother. Data are presented as number of women (percentage), mean (standard deviation) or median (range) as appropriate. McNemar test was used to compare the difference between the bother of OAB symptoms before and after operation, and the paired t test was used to compare the difference in the domain scores. Logistic regression was used for uni- and multivariate analysis. For logistic regression, the backward elimination procedure was used. Variables with a P1 indicates that the factor is positively correlated with the outcome variable; an OR2 2
Body mass index (kg/m ) Postmenopausal statusb Previous urogynaecological surgery Prolapse surgeryc Hysterectomyd Incontinence surgerye Type of surgery Anterior compartment Posterior compartment Central compartment Concomitant stress incontinence surgery Mesh Preoperative POP-Q stage Anterior
Posterior
Central
Moderate to severe bother preoperative OAB symptoms Frequency Urgency Urge incontinence Nocturia Other preoperative micturition symptoms Stress incontinence
1.1)a 1.6) 1.1)a 3.82) 1.4)
1.1) 1.0)a 1.7) 1.1)a 2.8)
1.5) 1.0)a 1.3)a 2.3) 1.5)
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Int Urogynecol J (2010) 21:1143–1149
Table 5 (continued)
Urinary retention
Yes No
Frequency OR (95% CI)
Urgency OR (95% CI)
Urge incontinence OR (95% CI)
Nocturia OR (95% CI)
16.5 (8.9; 30.8) Ref.
10.4 (5.7; 18.7) Ref.
10.2 (5.4; 19.1) Ref.
7.5 (4.2; 13.5) Ref.
All values with P
